Health inspection·April 29, 2024

F 0677 professional beautician. Level of Harm - Minimal harm or potential for actual harm Record Review of the April 2024 ADL Schedule revealed Resident#1 received showers and/or bed baths Monday, Wednesday and Friday on the 2pm - 10pm shift. Residents Affected - Few Record review of a facility shower schedule revealed Resident #1 was scheduled to receive a shower three times a week on Monday, Wednesday and Friday on the 2PM -10PM shift. Record Review of the PCC (electronic health record used to document information on each resident) notes for Resident#1 and dated 4/18/2024 at 3:37p) for a Change of Condition revealed, the Red Abrasion to back of scalp began on 4/18/2024. The NP was notified and new orders for clean site, apply Vaseline, LOTA Have TX Nurse Assess. Record review of Resident#1's physician's order dated 6/24/2016 revealed, Resident#1 had an order dated 4/18/2024 at 6:00pm to cleanse abrasion to back of scalp with wc; and on 4/19/2024 at 9:00am to cleanse abrasion to back of scalp w/ wc/pat dry, apply Vaseline, LOTA one time a day for abrasion until 4/19/2024 at 11:59pm. Record Review of PCC revealed, the wound care doctor rounded, assessed denuded (irritation) to the sacral area, new order to cleanse with normal saline/wound cleanser, pat dry, apply calcium alginate to wound bed, cover with bordered foam dressing daily and prn soiled or dislodged, well noted, order followed through, well tolerated. The FM was called to be updated on new orders, no response. Unable to leave a message due to no voicemail set up. During observation and on 4/24/2024 at 12:40pm, Resident#1 was laying in her bed and had a satin hair scarf. The Wound Nurse removed the scarf and Resident#1's hairstyle was in cornrows (braids). A small area on the back of her head was not braided. Unable to observe the open wounds on the scalp. Wound Nurse stated that Resident #1's scalp had an abrasion that appeared like someone may have scratched the back of her head in that area. During an interview on 4/24/2024 at 3:30pm with CNA A, revealed she has been caring for Resident#1 for some time now. She stated Resident #1 always scream; however, she can tell if the screams are for pain or other attention. She stated the Resident#1 is in a lot of pain due to her legs. She states both legs are contracted and sometimes it's difficult giving her a bath or shower and not being in pain. She states the resident can say yes or no. She states if the residents seem to be in a lot of pain and it is off the time of the medication schedule, she will contact the charge nurse. CNA A states she does comb resident's hair during bed baths; however, because her neck is stiff, she is unable to get to the bottom part of the back of her head. She states when she noticed the hair beginning to get matted at the back, she told the resident's FM to see if there may be someone, he knew that could come and do her hair. She stated when she returned to work after 2 days off, the resident hair was braided. In an interview on 4/24/2024 at 3:40pm interview with the Beautician revealed, on Saturday 4/13/2024 the FM came to the salon and said Resident #1 needed her hair done because her hair looked like it was matted. She told him she would be back at the facility on Thursday 4/18/2024 and would do her hair then. On 4/18/24 she did Resident#1's hair, which was extremely dirty and matted. In her professional opinion, the Beautician stated Resident #1's hair appeared it had not been combed or washed over a period time. She stated based on how dirty the Resident #1's hair was, in her professional opinion, it appeared her hair had not been washed in at least 3-4 months. It was completely matted to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 the hair tie on the back of her head used to maintain a ponytail. Level of Harm - Minimal harm or potential for actual harm The Beautician further revealed the FM's were in the facility and she summoned them into the beauty shop where she informed them that Resident #1's hair would have to be cut because it was matted. She was given permission to do so. Afterwards, she began to wash her hair and observed Resident#1 crying and screaming. The Beautician stopped washing her hair and looked closer at her scalp. At that time, she observed the open wounds on the scalp. She stated the type of wounds Resident #1 had occurred was a result of her hair not being washed; being matted and the scalp not having air to breath. She stated this could infect the scalp, which is what has happened to the resident over a period. She stated she took a photo of it while the family was there. She stated the FM observed the same thing. She stated she sent the photo to the staff over the activity department. The Beautician also revealed she has a double State of Texas License, one as an instructor for cosmetology students and the other as a actual beautician. She states she has over 20 years in the hair care industry. Residents Affected - Few In an Interview on 4/25/2024 at 11:20am with CNA B, he stated he has cared for Resident#1 for the 8 months he has worked in this facility. CNA B observed a rubber band in the back of Resident #1's hair, which is where her hair is matted. He has tried combing her hair, but it would be tangled, and Resident #1 would be in pain so he would stop. CNA B indicated he did not know why her hair was matted but it just got tangled up. In an Interview on 4/25/2024 at 1:40pm with the ADON it was revealed, she was aware of the issue with Resident#1's head. She stated the Activity Director informed her the resident had something in her head that the Beautician had found. The ADON stated she went to Resident #1's room and observed a round red area in the back of her scalp much like the scalp had been irritated. It did not have any depth to it or draining. The ADON believes the scalp was irritated because Resident #1 did not like her hair to be combed and as a result the scalp became irritated. The ADON stated she notified the NP and she gave an order to clean it and apply Vaseline and let the treatment nurse assess it. She stated she tried to call family member. Stated the FM were there; however, she never spoke with them. She stated she has never documented a resident not allowing staff to comb their hair. She Stated it should be care planned because it is more often than not that staff is allowed to comb her hair. The ADON stated Resident #1 receives her baths on Monday, Wednesday and Friday. She stated Resident #1 has refused bathing on occasion. When that happens, the CNAs are required to tell the nurses and the nurse should go in and speak with the resident. The ADON stated the hair washing and combing is a part of the bed bath and shower schedule; however, if a resident refused any part (ex., oral care or hair care) of the ADL there is no documentation. Interviewed on 4/25/2024 at 2:00pm with the DON, it was revealed she is aware of Resident #1's hair being matted. She believed it is matted because the Resident#1 will not allow the CNAs to comb her hair in the back. She stated it is not a wound, it was not open nor was it draining. She stated if it was a wound, then there would have been an order for triple biotics. She stated it appeared to only be an abrasion; it was not a wound and it is no longer on her scalp. She further stated the CNAs have tried to get the FM to pay for a beautician on previous occasions, but he just ignored the request. She states there is no documentation from staff regarding conversations with the FM regarding Resident #1's hair. She stated that washing hair is part of a CNA's responsibility when they give showers and some bed baths. The DON revealed, Vaseline was appropriate for Resident #1 because the skin on her scalp was not open. Stated she went to see Resident #1's head and there wasn't anything there. She stated Resident #1 was seen by the Wound Nurse as well. In a telephone interview on 4/26/24 at 12:40pm with Resident #1's PCP, it was revealed she was not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676371 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Windsor Quail Valley Post-Acute Healthcare 3640 Hampton Dr Missouri City, TX 77459 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm notified of an issue with her head, so she did not complete an examination of head/scalp area. The PCP states Resident#1's health was on the decline, so she visits her weekly. In an interview with FM on 4/29/2024 at 11:52AM, FM stated he took the initiative to find a beautician for Resident #1's hair because it was matted and didn't look like it had been washed. Residents Affected - Few During a telephone interview on 4/26/24 at 12:59pm with the NP revealed she received a call from the ADON regarding Resident#1's scalp but did not receive any pictures. She stated she was informed that Resident #1's scalp in the back was slightly red and there were no open wounds/open areas. Because there were no open wounds, she stated she may have told the ADON to put Vaseline on the area on the back of the head but can't recall saying anything about Vaseline. The NP stated if she was advised of any skin tear, small or large, she would have advised the ADON to apply an anti-biotic cream/ointment and not Vaseline. A record review of Resident #1's bed bath and shower schedule dated 3/27/2024 through 4/24/2024, revealed she received her bed bath and shower three times per week as per schedule and there are no indications of refusals. A record review of the facility's ADL policy dated 5/26/2023 revealed, care services of bathing, dressing, and oral care. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676371 If continuation sheet Page 4 of 4